Most pregnant women with Zika will eventually wind up at academic medical centers for prenatal care and delivery by a perinatologist, with newborn care provided by a comprehensive team of pediatrician sub-specialists including neonatologists and pediatric neurologists. The earlier during the pregnancy the better!
Highlights from August’s Emergency Preparedness Coordinating Council
Kevin Chason, DO, of the Mount Sinai Health System, shared how his system uses the emergency management structure to coordinate preparedness and response to Zika virus. A multidisciplinary team co-led by representatives from the emergency management and infection control departments has been meeting regularly since May. Key focus areas are patient communication, provider guidance, tracking and monitoring of specimens, and staff safety.
Zika continues to infiltrate US, 20 babies born with Zika-related birth defects
Twenty babies in the U.S. have been born with Zika-related birth defects and 749 pregnant women have lab evidence of possible Zika infection as of Sept. 15, according to the CDC’s most recent update.
There are 3,358 people in the U.S. with the mosquito-born and sexually transmitted virus in the U.S. as of Sept. 21. Of those, 28 people were infected via sexual contact.
Additionally, the CDC reported 43 of the total cases were acquired from mosquitoes in Florida. However, the Florida Department of Health lists its number of locally acquired Zika cases at 92 as of Sept. 22.
Doctors Brace for Zika Babies
This month, the first group of babies in Puerto Rico known to have been exposed to the Zika virus in their first trimester are being born. Pediatricians do not know what to expect.
“This is not like any other outbreak or epidemic,” said Dr. Fernando Ysern, a pediatrician in Caguas, Puerto Rico, who is the president of the Puerto Rico chapter of the American Academy of Pediatrics.
In the pediatric field, Zika looms as a kind of developmental doomsday virus, attacking the vulnerability of early brain development, striking at the neurological basis of human potential. While Puerto Rico, a United States territory, will experience the first wave of children affected by Zika, the rest of the United States is bracing for the spread of the virus.
Everyone knows, including our physicians, that proper hand washing is the most effective patient safety measure right?
Your physician and other clinicians (e.g. nurses, PTs, lab techs drawing blood) should wash their hands before and after each patient, and when beforehand wash in front of the patient.
Do you ask “Doctor, Did You Wash your Hands?” If not, why not?
First some history.
“Ignaz Semmelweis, a young Hungarian doctor working in the obstetrical ward of Vienna General Hospital in the late 1840s, was dismayed at the high death rate among his patients.
He had noticed that nearly 20% of the women under his and his colleagues’ care in “Division I” (physicians and male medical students) of the ward died shortly after childbirth. This phenomenon had come to be known as “childbed fever.” Alarmingly, Semmelweis noted that this death rate was four to five times greater than that in “Division II” (female midwifery students) of the ward.
One day, Semmelweis and some of his colleagues were in the autopsy room performing autopsies as they often did between deliveries. They were discussing their concerns about death rates from childbed fever.
One of Semmelweis’ friends was distracted by the conversation, and he punctured his finger with the scalpel. Days later, Semmelweis’ friend became quite sick, showing symptoms not unlike those of childbed fever. His friend’s ultimate death strengthened Semmelweis’ resolve to understand and prevent childbed fever.
In an effort to curtail the deaths in his ward due to childbed fever, Semmelweis instituted a strict hand washing policy amongst his colleagues in “Division I” of the ward. Everyone was required to wash their hands with chlorinated lime water prior to attending patients. Mortality rates immediately dropped from 18.3% to 1.3% in 1848 in Semmelweis’ division. (A)”
(1861) “…. Louis Pasteur was showing the world that microorganisms did indeed exist, that they acted on our world in myriad ways and that the ancient wisdom about “bad vapors” and spontaneous generation were wrong. Dead wrong. Prior to Pasteur and what would become known as “germ theory,” the prevailing theories held that organisms, like maggots and fleas, were spontaneously originated from other matter, like raw meat or diseased flesh…..
Pasteur is credited with opening the world’s eyes to the new science of microbiology and ushering in a brand new form of preventive medicine: immunization. …Building on what Pasteur was discovering, British surgeon Lister began to use this new germ theory to demonstrate the lifesaving value of disinfectant. Despite his skill at surgery, Lister knew that half his amputee patients would die of infection after the procedure…..
He began to treat his surgery equipment, before and after use, with carbolic acid. He also treated his patients’ wounds with it…..within two years, operative mortality decreased from nearly 50 percent to just 15 percent.” “Much of the greatness of Pasteur and Lister lies in their dogged persistence to spend 20 years convincing the rest of the medical world of the truth of their investigations,” ….. (B)
“What Dr. Towsend did next was something that Joseph Lister, despite years spent traveling the world, proving the source of infection and pleading with physicians to sterilize their hands and instruments, had been unable to prevent. As the president (Garfield) lay on the train station floor, one of the most germ-infested environments imaginable, Towsend inserted an unsterilized finger into the wound in his back, causing a small hemorrhage, and almost certainly introducing an infection that was far more lethal than Guiteau’s bullet.” (C) (1881)
FAST FORWARD 150 YEARS. 50% COMPLIANCE.
“Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’
It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse: Have you washed your hands?
Hospitals are encouraging patients to be more assertive, amid growing concern about infections that are resistant to antibiotics.
Strict hand hygiene measures are the gold standard for reducing infections associated with health care. Acquired primarily in hospitals but also in nursing homes, outpatient surgery centers and even doctor’s offices, they affect more than one million patients and are linked to nearly 100,000 deaths a year, according to the Centers for Disease Control and Prevention.
The CDC aims to engage both patients and caregivers in preventing dangerous hospital infections. Centers for Disease Control.
Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. (D)
In can be done! “How a team of doctors at one hospital boosted hand washing, cut infections and created a culture of safety.” (E)
BUT! THE MOST EFFECTIVE SOLUTION IS FOR YOU AS A PATIENT TO ASK “Doctor, Did You Wash your Hands?” Every time!
(C) DESTINY OF THE REPUBLIC, 2011
To fight Zika, Central Florida hospitals and doctors ramp up patient education, surveillance
In the fight against the spread of Zika, local doctors and hospitals are ramping up education and surveillance in Central Florida to contain the spread of the virus.
There is a heavy emphasis on patient education, while providers are on high alert for travel histories and on the lookout for potential cases that should be tested for Zika.
“There’s a limit in what we can do to reverse the effects of Zika,” said Dr. Vincent Hsu, hospital epidemiologist at Florida Hospital. “So what we do is a combination of supportive care and making sure that babies are referred to the right specialists. It’s really ensuring that there’s coordination of care among specialties.”
“We haven’t had pathogens in the past that have done all of these,” said Dr. Asim Jani, hospital epidemiologist for Orlando Health.
Jani and Hsu are former CDC disease detectives. The two have been collaborating since earlier this year to align their health systems’ Zika preparation efforts, most of which involve updating and educating their staff on the evolving Zika screening and testing guidelines.
The two systems, which have well-established labor and delivery units and maternal-fetal specialists, have also taken on the responsibility of caring for pregnant women who test positive for the Zika virus.
Johns Hopkins Opens Unique Comprehensive Care Center for Zika Virus Led by the Wilmer Eye Institute
As the number of patients with Zika virus grows worldwide, Johns Hopkins Medicine announces the opening of the new Johns Hopkins Zika Center, dedicated to caring for pregnant women and newborn babies, but also men and women of all ages with the mosquito-borne and sexually transmitted virus. The center will focus not only on diagnosis and treatment of infected individuals but also on the assessment of long-term effects, as well as new approaches to prevention and treatment of Zika virus infection. It is composed of providers and staff members from adult and pediatric departments and divisions within Johns Hopkins Medicine and the Johns Hopkins Bloomberg School of Public Health, including cellular engineering, epidemiology, infectious diseases, maternal-fetal medicine, neonatology, neurology and neurosciences, ophthalmology, orthopaedics, pediatrics, physiotherapy, psychiatry, psychology and social work. Medical experts from Brazil, a country greatly affected by Zika virus, are also members of the center.
As many of you know I have been advocating (unsuccessfully) for the designation of Zika Regional Referral Centers (ZRRFs).
Perhaps this article from STAT will convince policy makers that it is time to stage Zika hospital preparedness.
With little known about Zika virus, hospitals scramble to stay ahead
By Andrew Joseph https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/
“The threat of Zika virus is reshaping operations at hospitals across the country, as medical teams rush to figure out how best to provide care for pregnant women with the disease and monitor and treat babies with related brain damage.
With scientists still trying to better understand the virus — and without any treatments available — hospitals have been forced to adapt to a changing Zika outbreak, particularly in states such as Florida, Texas, and New York that are at risk for local transmission or have seen large numbers of travel-related cases.
Hospitals say they have built up their diagnostic tools, started performing more regular ultrasounds for patients, and are keeping closer-than-usual watch on amniotic fluid levels and fetal heart rates. Social workers and physical, speech, and occupational therapists are preparing to work with babies born with Zika-associated defects, should they require their care.”
“To bridge the gap, hospital officials say they have assigned doctors to keep up with the growing body of literature and confer with public health agencies. They are also bringing together obstetricians trained in high-risk pregnancies, pediatrician specialists, and virologists and other biomedical researchers.
Doctors say they don’t have good answers yet to the most pressing questions they get from pregnant patients, including if their fetuses are at risk throughout the pregnancy or only certain stages, and how likely their children are to have some sort of developmental problem.
Doctors also worry about what might happen to children who appear to be fine at birth. In the case of other congenital infections like cytomegalovirus, hearing and vision problems can emerge in apparently healthy children years down the road.”
To read the full STAT article click on https://www.statnews.com/2016/08/17/hospitals-zika-virus-disease-birth-defects/
CDC’s revised Zika Interim Response Plan (July) states: ”Neither vaccines nor proven clinical treatments are expected to be available to treat or prevent virus infections before local transmission begins within CONUS or Hawaii.”; “Scientific understanding of Zika virus continues to evolve, and new characteristics of the virus and how it is spread may arise.” (A)
“CDC director Tom Frieden has said that the mosquitoes carrying Zika in Miami could be developing resistance. Researchers can project what Zika infection rates will look like in multiple scenarios, but not what will happen if Zika is evolving at the DNA level or if its vectors multiply beyond sex and mosquitoes, both of which are real possibilities.” (B)
The New Jersey and New York Departments of Health Zika pages focus on community awareness, default to CDC, then stop at the door to the hospital ER. (C)
So we are not dealing with Zika “evidenced based medicine” but “best practices” aggregated and amended from Swine Flu, Ebola, Dengue, and other mosquito transmitted viruses.
Examples of some recent news reports make it clear that Zika parameters are changing so quickly, that only medical school affiliated teaching hospitals should be caring for Zika patients.
- “Zika virus infection during pregnancy may be related to a severe birth defect called arthrogryposis, whereby the joints – particularly those in the arms or legs – are deformed. This is the finding of a new study published in The BMJ.” “Researchers focused on seven babies whose mothers were infected with Zika while pregnant. Six of the seven developed microcephaly— the most widely publicized birth defect from Zika— but six also had trouble swallowing, six had clubfoot, five had eye abnormalities, and two needed breathing and feeding tubes.” (D)
- “NEW ORLEANS — Officials at the front lines of fighting the Zika virus are warning residents that mosquitos that carry the disease are already here.” (E)
- “Texas reported its first Zika-related death Tuesday after a baby girl whose mother traveled to El Salvador while pregnant died shortly after birth in a suburban Houston hospital. The girl, who died a few weeks ago, had microcephaly linked to the Zika virus….” (F)
- “In an effort to detect any local transmission of the Zika virus, the New York City Department of Health and Mental Hygiene said on Tuesday that it had expanded the guidelines on who should be tested for the disease to include anyone with its most-common symptoms.” (G)
- “Amid news of a Zika outbreak in the Miami area, the U.S. Food and Drug Administration’s Center for Veterinary Medicine (FDA-CVM) has cleared the experimental release of genetically modified (GMO) mosquitoes in the Florida Keys to help combat the virus. “ (H)
- “Suncoast Blood Bank announces they are testing all donated blood for the Zika virus. Effective immediately the blood bank will test all donors for the virus.” They say this is a proactive measure to protect the community blood supply.” (I)
- “I got Zika. The US health care system had no idea what to do with me. How do you spell Zika?”I stood at the front desk of a major Washington, DC, hospital last month. I had a head-to-toe rash that developed after I’d returned from the Dominican Republic, where Zika is much more common than it is stateside. The friend I’d traveled with was showing symptoms of the virus. I’d come to the emergency room to find out if I had it too.This was not a question I wanted to hear from the man who was checking me in.But ignorance of what Zika is, and uncertainty about how to deal with it, was common in my quest to get diagnosed — even from parts of the medical community that I expected would know what to do.” (J)
- “On Thursday, scientists described two cases in which the semen of men who contracted Zika in Haiti early this year continued to test positive for the virus, even though it has been six months since they were infected.The semen of one tested positive 188 days after he first experienced symptoms of the illness. Testing on day 181 came back positive for the other man. Both men are still being followed. Previously, the longest period in which evidence of virus was seen in the semen of a Zika-infected man was 93 days.” (K)
- “Until this week, there had been no reported cases of birth defects related to Zika in Canada.Public health officials are releasing no other information about the fetus, including whether or not he or she is alive. It represents the second confirmed case of maternal-to-fetal transmission of the Zika virus in Canada.” (L)
- “U.S. Sen. Bob Menendez can add a personal motivation to his efforts to get Congress to approve federal funding to combat the spread of the Zika virus. Menendez said this week his daughter is five months’ pregnant in Miami with his first grandchild.”(M)
- “Beyond Zika: How Congress Is Flirting With Medical Disaster. The dysfunctional response to the Zika virus lays bare a system that is increasingly ill-equipped to respond to outbreaks.” (N)
- “While the Zika virus has its moment, few people are discussing the problems underlying the worldwide increase in emerging infectious diseases.” (O)
- “Zika fits into the category of unforeseen emerging threats that migrate into new environments where they suddenly pose major hazards to unprepared populations — think severe acute respiratory syndrome (SARS) or Ebola, for instance. These required “urgent mobilization to protect and manage the introduction of these alien, and dangerous, pathogens,”….(P)
Soooooo……if you are concerned that you may have been exposed to Zika, until there are national protocols in place, bypass your community hospital ER, and go to the nearest medical school affiliated teaching hospital.
EMERGENCY ROOMS are not all created equal! (Q)
Stop the name games! University hospitals and regional medical centers should live up to their billing. (R)
(C) http://www.nj.gov/health/cd/zika/ https://www.health.ny.gov/diseases/zika_virus/
Many of you might be familiar with my advocacy for designating Zika Regional Referral Centers. If not see links below.
We don’t know what we don’t know” – The challenge to emergency preparedness….. http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/
Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/
Suspending a chicken over your bed could protect against Zika virus and malaria (A) http://doctordidyouwashyourhands.com/2016/07/suspending-a-chicken-over-your-bed-could-protect-against-zika-virus-and-malaria-a/
Zika “panic” – IS YOUR HOME TOWN READY FOR ZIKA?
Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.
Remember when a hospital was just a hospital, and its reputation spoke for itself? Now we have a plethora of self named healthcare institutions such as clinics, community hospitals, institutes, medical centers, national hospitals, specialty hospitals, and teaching hospitals.
My home state of New Jersey, for example, started with one children’s hospital in Newark, followed by a few more designated under state Health Department competitive certificate-of-need guidelines, followed by a few politically designated by the Legislature, followed by a bunch of sound-alikes such as a “children’s medical center” mischievously bypassing the fact that “children’s hospital” is a legislatively restricted name.
For the most part these appellations are used to define the hospital to its community and publicly compare it most positively to other nearby competitors. However, more and more hospitals are now calling themselves regional medical centers and university hospitals. These are very robust terms, sometimes used interchangeably or together, and imply characteristics such as comprehensive critical-care services, cardiac surgery/interventional cardiology, comprehensive stroke care, an academic environment, the latest cutting-edge technology, and a full-time cadre of 24/7 on-site superspecialist physicians, including intensivists.
And the not-so-subliminal message is that when you are very sick or injured you should bypass your local hospital.
The reality is that in New Jersey a hospital can call itself whatever it wants—there is no name regulation or oversight by state authorities. A few years ago Robert Wood Johnson University Hospital challenged and lost, when St. Peter’s Hospital added “University” to its name. Since then a number of other hospitals have added “University” as well, and more will follow. Certainly this phenomenon is not limited to New Jersey.
The Association of American Medical Colleges states: “Teaching hospitals are providers of primary care and routine patient services, as well as centers for experimental, innovative and technically sophisticated services. Many of the advances started in the research laboratories of medical schools are incorporated into patient care through clinical research programs at teaching hospitals.”
I believe a university hospital/regional medical center should have most of the following characteristics typical to “major league” hospitals:
■ First and foremost, it should have a written affiliation agreement with a medical school that includes the rotation of medical students to the hospital for required third year clinical rotations in internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery.
■ The hospital should have full-time chairmen in the core clinical departments (e.g., medicine, pediatrics, surgery) selected by a joint hospital-medical school search committee, and not as a reward for seniority or admitting a lot of patients.
■There should be at least three physician residency-training programs under the supervision of the medical school.
■ All physicians teaching students and residents should qualify for faculty appointments at the affiliated medical school.
■ A dean’s committee composed of senior medical and administrative staff from the hospital and school should meet regularly to jointly set strategic priorities and evaluate program efficacy and performance.
■ The hospital’s medical staff bylaws should mandate automatic removal from the staff of any physician who does not achieve board certification after a given period of time, such as five years.
■ The hospital should have at least three state-designated critical-care services such as trauma center, regional perinatal center (high-risk obstetrics), stroke center, children’s hospital or cardiac surgery. There should be full-time intensivists in all ICUs.
■The hospital should be a member of all major statewide multihospital clinical-care quality projects such as the New Jersey Hospital Association’s ICU and pressure-ulcer collaboratives. It should participate in clinical trials that the medical school has undertaken, and be a training site for students in nursing, pharmacy, physical therapy and other health professions.
■It should have a full-time chief medical officer, a senior physician preferably with a master’s degree earned through the American College of Physician Executives (or equivalent) and a chief nursing officer with an appropriate doctoral degree.
■Finally, the hospital’s board, administration and medical staff must have a demonstrable unwavering “safety net” commitment to the medically underserved.
These steps are, of course, easier said than done, so here are some initial steps for the states to consider:
State hospital associations should set up task forces to develop a policy and strategy to make sure hospital names are educational to the public, not exaggerations of capability.
A state could pass a law or the health department could promulgate regulations defining the requirements to be designated a university hospital or regional medical center. These designations should be subject to periodic state review.
Obtaining the appropriate and best hospital care should not be complicated by creative and clever hospital marketing but by easily understandable evidenced-based standards and metrics—and names.
* By Jonathan M. Metsch, Dr.P.H., August 18, 2008 • Modern Healthcare
My first experience with hospital administrative titles was in 1967 as a 2nd Lieutenant in the Air Force assigned to Wilford Hall USAF Medical Center in San Antonio. The Hospital Commander was a physician Brigadier General. That was the only title/ rank that mattered.
Returning to NYC in 1972 a typical hospital had a President & CEO, EVP & COO, and an SVP & CFO.
I was taught that President was a title and CEO was a function, nonetheless over time many hospital leaders started referring to their title as CEO, a trend that continues.
On a rapid trajectory we have seen hospitals become regional hospital systems focusing on becoming integrated health care delivery systems, to mega systems focusing on geographic reach, to super-size systems which have started or taken over medical schools, functioning almost like insurance companies and investment banks.
And with that an explosion of C-Level titles.
But I digress.
So now we have, for example (curated from hospital web sites. Really!)….. Chief Medical Officer, Chief Information Officer, Chief Revenue Officer, Chief Affiliation Officer, Chief Learning Officer, Chief Experience Officer, Chief Managed Care and Business Development Officer, Chief Quality Officer, Chief Development Officer, Chief Public Relations Officer, Chief Procurement Officer, Chief Human Resources Officer, Chief Legal Officer, Chief Corporate Compliance Officer, Chief Financial Officer, Chief Operating Officer, Chief Marketing and Communications Officer, Chief Administrative Officer, Chief Nurse Executive, Chief Academic Officer, Chief Strategy Officer, Chief Information Officer, Chief Population Health Officer, Chief Diversity and Inclusion Officer, Chief Risk Officer, Chief Investment Officer, Chief Medical Information Officer, Chief Clinical Integration Network Development Officer, Chief Technology Officer, Chief IT Officer, Chief Sustainability Officer.
“We are living in the age of flattening org structures with the hope of making organizations more fair and efficient, yet employees still want to feel important (like they are progressing up the chain). This is the environment where title wackiness is allowed and encouraged to happen.” (A)
“The snag is that the familiar problems of monetary inflation apply to job-title inflation as well. The benefits of giving people a fancy new title are usually short-lived. The harm is long-lasting. People become cynical about their monikers (particularly when they are given in lieu of pay rises).” (B)
“What began with a C-suite of corporate leaders has morphed into a full-fledged assault on traditional chains of command, with a seemingly endless cascade of increasingly specialized, yet amorphous, positions in an unwieldy hodgepodge of matrixed responsibilities. It’s title inflation at its worst and often counterproductive to effective management.” (C)
C-Level titles have become so pervasive in some mega-systems it is unrealistic that they all report to the CEO or COO. So to reflect the operating TO it is likely a new top-tier-title strata will be necessary to explain who is really in charge and has final authority. Starting with something like Deputy CEO which will later become First Deputy CEO and later Senior First Deputy CEO – then similar clarifiers throughout the C-Suite.
Skipping a level up we already see major hospital systems with numerous Presidents presiding over different types of entities (e.g., hospitals, insurance companies, physician practices, imaging & urgi and surgi centers) and again, at some point differentiators will need to be added.
The key to the future might be the designation of a “Chief Corporate Title Tracking Officer”, unless the rumored so-called “C-Level Title Non- Proliferation Treaty” being advanced by some major academic medical centers becomes a reality.
And of course I am guilty too…using four academic titles…Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai; Adjunct Professor, Ziklin School of Business, Baruch College, C.U.N.Y.; Adjunct Professor, Rutgers School of Public Health; & Adjunct Professor, Rutgers School of Public Affairs and Administration.